Medical Policy Updates

Medical Policy Update for October 29, 2019

Medical Guidelines Reason for Update
Ambulatory Event Monitors Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
ANA/ENA Testing AHS - G2022 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Anesthesia Services Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Baroreflex Stimulation Devices Regulatory status updated with recent approval by FDA for Barostim Neo System. Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
BCR-ABL1 Testing for Chronic Myeloid Leukemia and Acute Lymphoblastic Leukemia AHS - M2027 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Biochemical Markers of Alzheimers Disease AHS - G2048 In the section "When Biochemical Markers of Alzheimers Disease are not covered", the wording "is considered investigational" is changed to read: "is not covered." Policy noticed 8/13/19 for effective date 10/15/19. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases AHS - G2123 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
BRCA AHS - M2003 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed
Cardiac Monitoring Devices in the Outpatient Setting Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Carotid Intimal-Medial Thickness References updated. Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Cervical Cancer Screening AHS - G2002 Reviewed by Avalon Q3 CAB. No change in policy intent. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Chromosomal Microarray AHS - M2033 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Colorectal Cancer Screening AHS-B0001 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Computed Tomography to Detect Coronary Artery Calcification References updated. Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Cryosurgical Ablation of Primary or Metastatic Liver Tumors Reference added.
Dental Criteria for use of Hospital Inpatient or Outpatient Facility Services or Ambulatory Surgery Center Facility Services Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Dental Reconstructive Services Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Dermatologic Applications of Photodynamic Therapy References and Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Diagnosis of Idiopathic Environmental Intolerance AHS - G2056 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Diagnostic Testing of Influenza AHS - G2119 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed
Diagnostic Testing of Iron Homeostasis and Metabolism AHS - G2011 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed
Diagnostic Testing of Sexually Transmitted Infections AHS - G2157 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed
DNA Ploidy Cell Cycle Analysis AHS - M2136 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Edaravone (Radicava™) Specialty Matched Consultant Advisory Panel review 10/16/2019
Enhanced External Counterpulsation (EECP) Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Epithelial Cell Cytology in Breast Cancer Risk Assessment AHS - G2059 In the "When Epithelial Cell Cytology in Breast Cancer Risk Assessment is not covered" section, the investigational statement is revised to read: Cytologic analysis of epithelial cells from nipple aspirations as a technique to assess breast cancer risk and manage patients at high risk of breast cancer is not covered. Policy noticed 8/13/19 for effective date 10/15/2019. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Eteplirsen for Duchenne Muscular Dystrophy Reference added. Specialty Matched Consultant Advisory Panel review 10/16/2019.
Evaluation of Dry Eyes AHS - G2138 In the section "When Evaluation of Dry Eyes is not covered" the investigational statement is revised to read: "...is not covered". Policy noticed 8/13/2019 for effective date 10/15/2019. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Familial Adenomatous Polyposis and MUTYH-Associated Polyposis AHS-M2024 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Fecal Calprotectin Testing AHS - G2061 Wording in the "Policy", "When Covered", and/or "Not Covered" section(s) changed from "Medically Necessary" to "Reimbursement is allowed" or "Investigational" to "Reimbursement is not allowed" when necessary.
Flow Cytometry AHS-F2019 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Folate Testing AHS - G2154 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management AHS - M2166 No change to policy statements. Minor reformatting and edits.
Gene Expression Profiling for Uveal Melanoma AHS - M2071 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Gene Expression Testing for Breast Cancer Prognosis AHS - M2020 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
General Inflammation Testing AHS - G2155 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Cancer Susceptibility Panels Using Next Generation Sequencing AHS - M2066 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Expression Profiling and Genetic Testing for Familial Cutaneous Malignant Melanoma AHS - M2037 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed. No changes to Policy Statements.
Genetic Testing for Acute Myeloid Leukemia AHS - M2062 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Adolescent Idiopathic Scoliosis AHS - M2058 No changes to policy.
Genetic Testing for Alpha- and Beta- Thalassemia AHS - M2131 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for CHARGE Syndrome AHS - M2070 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medically Necessity to Reimbursement language, where needed.
Genetic Testing for Cystic Fibrosis AHS - M2017 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies AHS - M2072 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Duchenne, Becker, Facioscapulohumeral, Limb-Girdle Muscular Dystrophies AHS - M2074 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Epilepsy AHS - M2075 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Familial Alzheimer's Disease AHS - M2038 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Familial Hypercholesterolemia AHS - M2137 No change to policy statements. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Fanconi Anemia AHS - M2077 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for FMR1 Mutations AHS - M2028 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medically Necessity to Reimbursement language, where needed.
Genetic Testing for Germline Mutations of the RET Proto-Oncogene AHS - M2078 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Hereditary Hearing Loss AHS - G2148 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Hereditary Hemochromatosis AHS - M2012 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Hereditary Pancreatitis AHS - M2079 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Inherited Cardiomyopathies and Channelopathies AHS - M2025 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Lactase Insufficiency AHS - M2080 No change to policy statements.
Genetic Testing for Li_Fraumeni Syndrome AHS - M2081 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Lipoprotein A Variant(s) as a Decision Aid for Aspirin Treatment and/or CVD Risk Assessment AHS - M2082 No change to policy statements.
Genetic Testing for Neurofibromatosis and Related Disorders AHS - M2134 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for PTEN Hamartoma Tumor Syndrome AHS - M2087 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Genetic Testing for Rett Syndrome AHS - M2088 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Helicobacter Pylori Testing AHS - G2044 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Hemoglobin A1c AHS - G2006 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed
Hepatitis C AHS - G2036 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
HIV Genotyping and Phenotyping AHS - M2093 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Hormonal Testing in Males AHS - G2013 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Hyperbaric Oxygen Therapy Reference and Policy Guideline section updated. Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Hyperhidrosis, Treatment of References updated. Clarified "when not covered" section, to include Radiofrequency ablation to Table A Axillary, Plantar and Craniofacial as well as Microwave treatment to Plantar. Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Identification of Microorganisms using Nucleic Acid Probes AHS - M2097 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Immunohistochemistry AHS - P2018 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Infliximab, Infliximab-dyyb, Infliximab-abda, Infliximab-qbtx Under "When Covered," added the indication "Hidradenitis Suppurativa" with the following criteria: "to treat moderate to severe refractory hidradenitis suppurativa, and the patient has tried and failed, or is intolerant to, or has a clinical contraindication to adalimumab (Humira)," and removed "hidradenitis suppurativa" from "When Not Covered" section. Updated Policy Guidelines to reflect dosing and information for additional indication. References added. Medical Director review 10/2019.
Intra Articular Hyaluronan Injections for Treatment of Osteoarthritis of the Knee Updated table in Billing/Coding section to include Synojoynt and Triluron code, units, and injection quantity. No change to policy intent.
Intracellular Micronutrient Analysis AHS - G2099 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Laser Treatment of Onychomycosis Reference updated. Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Leadless Cardiac Pacemakers Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Light Therapy for Dermatologic Conditions References updated. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Lyme Disease AHS - G2143 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Marfan Syndrome AHS - M2144 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Mohs' Micrographic Surgery Specialty Matched Consultant Advisory Panel review 10/16/2018. No change to policy statement.
Molecular Analysis for Gliomas AHS - M2139 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Nerve Fiber Density Testing AHS - M2112 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Non-Pharmacologic Treatment of Rosacea Policy Guidelines and References updated. Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Nusinersen (Spinraza™) Reference added. Specialty Matched Consultant Advisory Panel review 10/16/2019.
Onasemnogene abeparvovec (Zolgensma®) Specialty Matched Consultant Advisory Panel review 10/16/2019.
Oral Screening Lesion Identification Systems and Genetic Screening AHS - G2113 Reviewed by Avalon 2nd Quarter CAB. Added SaliMark OSCC® (PeriRx) test to the Non Covered list. In the When Not Covered section, the investigational statement is revised to read "Oral screening, lesion identification systems and genetic testing are not covered for any use..." Code 81599 to Billing/Coding section. Medical Director review 8/2019. Policy noticed 8/13/2019 for effective date 10/15/2019. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Orthodontics for Pediatric Patients Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Orthognathic Surgery Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Pathogen Panel Testing AHS - G2149 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Percutaneous Tibial Nerve Stimulation for Voiding Dysfunction Reference added.
Prenatal Screening AHS - G2035 19 Reviewed by Avalon 3rd Quarter CAB. No change in overall intent of policy. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Prenatal Screening for Fetal Aneuploidy AHS - G2055 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Pre-Operative Testing AHS - G2023 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia References updated. Specialty Advisory Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Prostate Biopsies AHS - G2007 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Salivary Hormone Testing AHS - G2120 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Serum Testing for Evidence of Mild Traumatic Brain Injury AHS - G2151 New policy developed. BCBSNC will not provide coverage for serum testing for evidence of mild traumatic brain injury because it is considered to be investigational. BCBSNC does not provide coverage for investigational services. Medical Director review 8/20/2019. Policy noticed 8/27/2019 for effective date 10/29/2019.Codes 81479 and 84999 added to Billing/Coding section. Policy remains on notice until 10/29/2019.
Signal-Averaged ECG Specialty Matched Consultant Advisory Panel review 10/2019. Senior Medical Director review 10/2019.
Spinal Manipulation Under Anesthesia Specialty Matched Consultant Advisory Panel Review 10/16/2019. No change to policy statement.
Stem-cell Therapy for Peripheral Arterial Disease Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Temporomandibular Joint Dysfunction (TMJD) Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Testing for Mosquito or Tick-Related Infections AHS - G2158 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Testing for Targeted Therapy of Non-Small-Cell Lung Cancer AHS - M2030 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Testing of Homocysteine Metabolism Related Conditions AHS - M2141 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Thyroid Disease Testing AHS - G2045 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Tumor Tissue Mutation Analysis in Colorectal Cancer AHS - M2026 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Ultraviolet Light Therapy in the Home Setting(UVB) References updated. Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy statement.
Urine Culture Testing for Bacteria AHS - G2156 References and guideline description updated. Code table removed, and applicable codes listed. Statement added to when not covered section. "Follow-up urine culture testing for an uncomplicated urinary tract infection in patients that show evidence of clinical resolution of infection is considered not medically necessary." Policy noticed 8/27/19 for effective date 10/29/2019. Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Use of Common Genetic Variants to Predict Risk of Non-Familial Breast Cancer AHS-M2126 No change to policy statements.
Ustekinumab (Stelara®) Specialty Matched Consultant Advisory Panel review 10/16/2019. No change to policy intent.
Venous Thrombosis Risk Testing AHS - M2041 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Vesicoureteral Reflux, Treatment with Periureteral Bulking Agents Reference added.
Vitamin B12 and Methylmalonic Acid Testing AHS - G2014 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Vitamin D Testing AHS - G2005 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
Wearable Cardioverter Defibrillators References updated. Specialty Matched Consultant Advisory Panel review 10/2019. Medical Director review 10/2019.
Whole Genome and Whole Exome Sequencing AHS - M2032 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.
ZIKA Virus Risk Assessment AHS - G2133 Wording in the Policy, When Covered, and/or Not Covered section(s) changed from Medical Necessity to Reimbursement language, where needed.