Medical Policy Updates

Medical Policy Update for October 1, 2019

Medical Guidelines Reason for Update
Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Added the following indication to "When Covered" section: "the patient has HER2-positive early breast cancer and has residual invasive disease after neoadjuvant taxane and trastuzumab-based treatment," and added related clinical evidence to Policy Guidelines. Restructured Policy Statements for clarity. Minor edits and updates made throughout Description and Policy Guidelines sections for clarity. References added. Medical Director review 8/2019. Specialty Matched Consultant Advisory Panel review 8/21/2019.
Alpha-fetoprotein-L3 for Detection of Liver CA AHS-G2046 Archived per Avalon Q2 CAB review 2019. Medical Director review 8/2019.
Amniotic Membrane and Amniotic Fluid Injections Coding section updated with new codes effective 10/1/19. Added codes Q4205, Q4206, Q4208 - Q4221.
BCR-ABL1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia AHS - M2027 Under "When Covered" section: added 2. C. "Every 3 months for 2 years and every 3-6 months thereafter." Deleted 2.D. "After allogeneic HCT complete cytogenic response, every 3 months." Deleted coding table from Billing/Coding section and deleted CPT code 81403; added PLA codes: 0016U, 0040U for effective date 10/1/19. Medical Director review 8/2019.
Bioengineered Skin and Tissue Coding section updated with new codes effective 10/1/19. Added codes Q4222 and Q4226.
Bone Mineral Density Studies Specialty Matched Consultant Advisory Panel review 9/18/2019. References, descriptions, and policy guidelines sections updated. No change to policy statement.
BRCA AHS-M2003 Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement. Coding table deleted from Billing/Coding section. Medical Director review 8/2019.
CAR-T Therapy Added reference to the following related policy: "Polatuzumab vedotin-piiq (PolivyTM)". References added. Specialty Matched Consultant Advisory Panel review 8/21/2019. Added revenue codes 0870, 0871, 0872, 0873, 0874, and 0875 to Billing/Coding section.
Catheter Ablation as a Treatment for Atrial Fibrillation Description section, policy guidelines, and references updated. No change to policy intent. 7/2019.
Cellular Immunotherapy for Prostate Cancer Reference added. Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy intent.
Cemiplimab-rwlc (Libtayo®) Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy intent. Added HCPCS code J9119 to Billing/Coding section and deleted codes C9044, J3490, J3590, and J9999 effective 10/1/19.
Cetuximab (Erbitux®) Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy intent.
Colorectal Cancer Screening AHS-B0001 Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement. Deleted code table from Billing/Coding section. Medical Director review 8/2019.
Denosumab (ProliaTM, XGEVATM) Added reference to the following related medical policy: "Romosozumab-aqqg (EvenityTM)". Specialty Matched Consultant Advisory Panel review 9/18/2019. No change to policy intent.
Diagnosis of Vaginitis including Multi-target PCR Testing AHS - M2057 Policy statement revised to read: BCBSNC will provide coverage for diagnosis of vaginitis including multi-target PCR testing when it is determined the medical criteria or reimbursement guidelines noted below are met. Wording revised in When Covered section. "Medically Necessary" changed to "Reimbursement is allowed…" Wording revised in the Not Covered section. "Not Medically Necessary" and "investigational" changed to read "Reimbursement is not allowed…" Deleted coding grid.
Edaravone (RadicavaTM) Added the following continuation criteria to "When Covered" section: "the patient has been receiving edaravone treatment previously, and there is documentation of continued clinical benefit while receiving edaravone treatment indicated by slowing of the progression of the symptoms relative to that of the projected natural course of ALS." Medical Director review 9/2019.
Emapalumab-lzsg (GamifantTM) Added HCPCS code J9210 to Billing/Coding section and deleted codes C9050, J3490, and J3590 effective 10/1/19.
Enzyme Replacement Therapy (ERT) for Lysosomal Storage Disorders Specialty Matched Consultant Advisory Panel review 7/17/2019. No change to policy intent.
Extracorporeal Photopheresis Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement.
Familial Adenomatous Polyposis and MUTYH-Associated Polyposis AHS-M2024 Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement. Deleted coding table from Billing/Coding section. Medical Director review 8/2019.
Folate Testing AHS -G2154 Reviewed by Avalon 2nd Quarter 2019 CAB. Medical Director review 8/2019.
Gene Expression Testing for Breast Cancer Prognosis AHS-M2020 Reviewed by Avalon 2nd Quarter 2019 CAB. Under "When Covered" section 1: reordered and reworded bullets. Previous bullets A-I are now A-F. Deleted the coding table in Billing/Coding section as well as deleted CPT code 81400, and PLA code 00081. Added Related Policies section. Medical Director review 8/2019.
General Genetic Testing, Germline Disorders AHS - M2145 Reviewed by Avalon 2nd Quarter 2019 CAB. Minor revisions Description section and Policy Guidelines, and references updated. Code table removed from Billing/Coding section. Medical Director review 9/2019.
General Genetic Testing, Somatic Disorders AHS-M2146 Reviewed by Avalon 2nd Quarter 2019 CAB. Minor revisions only: Changed item #5 under the When Covered section to a "Note" and minor update to the Related Policies section. No change to policy statement intent. Medical Director review 9/2019.
General Inflammation Testing AHS -G2155 Medical Director review 8/2019. Reviewed by Avalon 2nd Quarter 2019 CAB.
Genetic Testing for 5 Fluorouracil Use in Cancer Patients AHS-M2067 Specialty Matched Consultant Advisory Panel review 8/21/19. Deleted coding table from Billing/Coding section. No change to policy intent. Medical Director review 8/2019.
Genetic Testing for Dilated Cardiomyopathy AHS - M2073 Q2 Avalon CAB review - policy archived.
Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS - M2025 Reviewed by Avalon 2nd Quarter 2019 CAB. Policy extensively revised to include description and guidelines for cardiomyopathies. Policy statement revised to include "cardiomyopathies" and as follows: to the When Covered section added items #8-14; When Not Covered section added 2 additional "not medically necessary" statements and 1 "investigational" statement regarding HCM; Added the following to the 2nd to last statement regarding Genetic testing for Early Repolarization "J-wave" Syndrome, Sinus Node Dysfunction (SND) and/or other rhythm disorders is considered investigational. Related Policies added to Description section. References updated. Medical Director review 9/2019.
Genetic Testing for Macular Degeneration AHS-M2083 Reviewed by Avalon 2nd Quarter 2019 CAB. Deleted coding table from Billing/Coding section. Medical Director review 9/2019.
Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy AHS - M2086 Q2 Avalon CAB review - policy archived. Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Genetic Testing for Statin-Induced Myopathy AHS - M2089 Q2 Avalon CAB review - policy archived.
Goserelin Acetate (Zoladex) Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement.
Hepatitis C AHS - G2036 Reviewed by Avalon 2nd Quarter 2019 CAB. Literature Review and Applicable Federal Regulations updated. Policy Guidelines updated. References updated. Coding table removed from the Billing/Coding section of the policy. Medical Director review 9/2019.
Hormonal Testing in Females AHS - G2161 References and policy guidelines updated. Reviewed by Avalon 2nd Quarter 2019 CAB. Medical Director review 8/2019. Coding table removed and codes listed. Added code 82024, 82642, 83003, 84146, 84443. Note 1 added to when not covered for symptom clarity. "for individuals with ambiguous genitalia, hypospadias, or microphallus" added to when not covered #7. When covered #4 added.
Hormonal Testing in Males AHS - G2013 Medical Director review 8/2019. Reviewed by Avalon 2nd Quarter 2019 CAB.
Infertility Diagnosis and Treatment Specialty Matched Consultant Advisory Panel review 9/18/2019. No change to policy statement.
Infliximab, Infliximab-dyyb, Infliximab-abda, Infliximab-qbtx Under "When Covered," edited list of contraindications to only include moderate to severe heart failure and previous severe hypersensitivity reaction to infliximab as labeled contraindications. Medical Director review 9/2019.
Intravitreal Implant Added HCPCS code J7314 to Billing/Coding section effective 10/1/19.
Lynch Syndrome AHS-M2004 Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement. Deleted coding table from Billing/Coding section.
Magnetic Resonance Imaging (MRI) Targeted Biopsy of the Prostate Description and Policy Guidelines updated. Change to Policy statements to include medically necessary criteria for coverage of MRI-targeted biopsy of the prostate after an initial negative TRUS guided biopsy or in a patient who is a candidate for active surveillance. Medical director review.
Mogamulizumab-kpkc (Poteligeo®) Added HCPCS code J9204 to Billing/Coding section and deleted codes C9038, J3490, J3590, and J9999 effective 10/1/19.
Molecular Markers in Fine Needle Aspirates of the Thyroid AHS - M2108 Specialty Matched Consultant Advisory Panel review 8/231/19. No change to policy statement. Deleted coding table from Billing/Coding section. Medical Director review 8/2019.
Molecular Panel Testing of Cancers to Identify Targeted Therapy AHS - M2109 Specialty Matched Consultant Advisory Panel 8/21/19. Reviewed by Avalon 2nd Quarter 2019 CAB. Added genes HER2, PALB2 for Breast Ca Solid Tumors and added gene MEN2A for Thyroid Ca. Deleted the coding table and deleted the following CPT codes from Billing/Coding section: 81170, 81206, 84999. Added the following PLA codes to the Billing/Coding section: 0022U, 0037U, 0048U, 0050U, 0056U, 0057U. Medical Director review 8/2019.
Moxetumomab pasudotox-tdfk (LumoxitiTM) Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy intent. Added HCPCS code J9313 to Billing/Coding section and deleted codes C9045, J3490, J3590, and J9999 effective 10/1/19.
Mutation Analysis in Myeloproliferative Neoplasms AHS - M2101 Reviewed by Avalon 2nd Quarter 2019 CAB. Under "When Covered" section added: NOTE: For 5 or more gene tests being run on the same platform, such as multi-gene panel next generation sequencing, please refer to AHS-R2162 Reimbursement Policy. Deleted coding table from Billing/Coding section. Medical Director review 8/2019.
Necitumumab (Portrazza) Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement.
Olaratumab (LartruvoTM) Added language to reflect market withdrawal on 7/31/2019 and contact information for the Lartruvo Patient Access Program for requests for CONTINUED ACCESS FOR PATIENTS CURRENTLY RECEIVING COMMERCIAL olaratumab. References added. Medical Director review 9/2019.
Pancreatic Cancer Risk Testing Using Molecular Classifier in Pancreatic Cyst Fluid AHS-M2114 Reviewed by Avalon 2nd Quarter 2019 CAB. Deleted coding table from Billing/Coding section. Medical Director review 8/2019.
Panitumumab (Vectibix®) Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy intent.
Pathogen Panel Testing AHS - G2149 Reviewed by Avalon 2nd Quarter 2019 CAB. Related Policies added to Description section. Revised the indications under the When Not Covered section to include the nature of the sample as well as UroSwab®. The following codes were added to the Billing/Coding section: 0068U, 0086U, 0097U, 0098U, 0099U, 0100U, and code table removed. References updated. Medical Director review 8/2019.
Patisiran (OnpattroTM) Added HCPCS code J0222 to Billing/Coding section and deleted codes C9399, C9036, J3490 effective 10/1/19.
PD-1 Inhibitors Under "When Covered" section for Pembrolizumab (Keytruda), added additional covered indications: melanoma with lymph node involvement following complete resection, as adjuvant treatment; NSCLC stage III disease and is not a candidate for surgical resection or definitive chemoradiation; metastatic squamous NSCLC as first-line treatment, in combination with carboplatin and either paclitaxel or paclitaxel protein-bound; metastatic SCLC with disease progression on or after platinum-based chemotherapy and at least one other prior line of therapy; metastatic or unresectable, recurrent HNSCC AND used as first-line treatment in combination with platinum and FU, OR the patient has PD-L1 tumor expression (CPS ≥1) as determined by an FDA-approved test, and used first-line as a single agent; HCC and has been previously treated with sorafenib; recurrent locally advanced or metastatic MCC; advanced RCC and used as first-line treatment in combination with axitinib. For clarity, added "use as single agent" for recurrent or metastatic HNSCC under "When Covered" for Keytruda. Updated "When Covered" section for Nivolumab (Opdivo) for clarity by adding "use as a single agent" for renal cell carcinoma, and "metastatic" for small cell lung cancer. Additional minor updates made to "When Covered" section for clarity. References added. Specialty Matched Consultant Advisory Panel review 8/21/2019.
PD-L1 Inhibitors New indication added to "When Covered" section for avelumab (Bavencio) for treatment of patients with advanced renal cell carcinoma (RCC). Description section updated to reflect addition of new indication. References added. Specialty Matched Consultant Advisory Panel review 8/21/2019. Medical Director review 8/2019.
Professional Pathology Billing Guidelines AHS - R2169 New reimbursement policy developed. BCBSNC will reimburse professional pathology services in accordance with the guidelines outlined in the policy. Policy noticed 7/30/2019 for effective date 10/1/2019.
Ravulizumab-cwvz (UltomirisTM) Added HCPCS code J1303 to Billing/Coding section and deleted codes C9052, J3490, and J3590 effective 10/1/19.
Romosozumab-aqqg (EvenityTM) Specialty Matched Consultant Advisory Panel review 9/18/2019. No change to policy intent. Added HCPCS code J3111 to Billing/Coding section and deleted codes C9399, J3490, and J3590 effective 10/1/19.
Serum Tumor Markers for Malignancies AHS - G2124 Specialty Matched Consultant Advisory Panel review 8/21/2019. Reviewed by Avalon 2nd Quarter 2019 CAB. Under "When Covered" section: K.d. added ovarian cancer workup. Under "When Not Covered" section: added investigational statement "The use of urokinase plasminogen activator (uPA) and plasminogen activator inhibitor type 1 (PAI-1) as serum tumor markers is considered investigational; added AFP-L3 (Lens culinaris agglutinin reactive AFP) as investigational; added REVEAL Lung Nodule Characterization as investigational. Under Billing/Coding section: deleted coding table. Added CPT codes 81500, 81538, 81551, 82107, 83950, 85415, 86305, PLA code 0092U; Deleted CPT codes 81525, 81539. Medical Director review 8/2019.
Tagraxofusp-erzs (ElzonrisTM) Added HCPCS code J9269 to Billing/Coding section and deleted codes C9049, J3490, J3590, and J9999 effective 10/1/19.
Talimogene Laherparepvec (ImlygicTM) Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement.
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS-M2030 Reviewed by Avalon 2nd Quarter 2019 CAB. Extensive revisions to "When Covered" section: Reordered and reworded indications, new statements for #2, 4, 5. Added note: For 5 or more gene tests being run on a tumor specimen (i.e. non-liquid biopsy) on the same platform, such as multi-gene panel next generation sequencing, please refer to AHS-R2162 Reimbursement Policy. Deleted coding table from Billing/Coding section and deleted CPT codes 81445, 81450, 81455. Medical Director review 8/2019.
Thyroid Disease Testing AHS - G2045 Reviewed by Avalon 2nd Quarter 2019 CAB. Medical Director review 9/2019. Removed coding table, codes listed instead. Clarified 1Eii section of when covered by adding the word total. When not covered section updated to include the exception "Total T4 testing for management of thyroid disease during pregnancy."
Topotecan Hydrochloride (Hycamtin) Specialty Matched Consultant Advisory Panel review 8/21/2019. No change to policy statement.
Transtympanic Micropressure Applications as a Treatment of Meniere's Disease Specialty Matched Consultant Advisory Panel review 9/21/2019.
Trastuzumab Under "When Covered," added Kanjinti (trastuzumab-anns) biosimilar to Herceptin (trastuzumab) for the treatment of HER2 overexpressing breast cancer and HER2 overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma. Added reference to related policies for Perjeta, Kadcyla, and Tykerb. Added HCPCS codes Q5117, C9399, J3490, J3590 to Billing/Coding section effective 10/1/19. References added. Medical Director review 9/2019.