Medical Policy Updates

Medical Policy Update for September 10, 2019

Medical Guidelines Reason for Update
Abdominoplasty, Panniculectomy and Lipectomy Specialty Matched Consultant Advisory Panel review 8/20/2019. No change to policy statement.
Amniotic Membrane and Amniotic Fluid Injections Specialty Matched Consultant Advisory Panel 8/20/2019. Verbiage added to "when covered" and "when not covered" section "With the exception of products used within the scope of FDA indications for treatment of burns and rare skin conditions such as recessive dystrophic epidermolysis bullosa, FDA approval for a specific use does not define that product as non-investigational."
Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions Reference added. Policy Guidelines updated. Specialty Matched Consultant Advisory Panel review 7/30/2019.
Bioengineered Skin and Tissue Specialty Matched Consultant Advisory Panel 8/20/19.
Breast Surgeries Clarifying statement added to "When not covered" in Sections 1 and 5. Added wording "medically necessary risk-reducing mastectomy." Society guidelines added to section IV and references added. No change to policy intent. Specialty Matched Consultant Advisory Panel 8/20/2019.
Chromosomal Microarray AHS - M2033 Medical Director review 1/1/2019. Policy noticed 1/1/2019 for References and policy guidelines updated. Coding table removed, added code 81265. For clarity, the term "Postnatal" was added to when not covered section so it now states that Postnatal chromosomal microarray testing. Maternal cell contamination (MCC) analysis performed in parallel with fetal diagnostic testing is medically necessary (based on both AMP and ACMG guidelines). Added to when not covered section "except for microarray for neoplasia."
Composite Allotransplantation of the Hand and Face Specialty Matched Consultant Advisory Panel 8/20/2019. Policy guidelines updated, no change to policy statement.
Computer Assisted Surgical Navigational Orthopedic Procedures Reference added. Specialty Matched Consultant Advisory Panel review 7/30/2019.
Continuous Monitoring of Glucose in the Interstitial Fluid References added and evidence summary updated to include type 2 diabetes and Eversense CGM. Policy statement updated to include type 2 diabetes as medically necessary for continuous and intermittent monitoring.
Continuous Passive Motion in the Home Setting Specialty Matched Consultant Advisory Panel review 7/30/2019.
Cosmetic and Reconstructive Surgery Specialty Matched Consultant Advisory Panel 8/20/19. No change to policy statement.
DNA Ploidy Cell Cycle Analysis AHS - M2136 Reviewed by Avalon 2nd Quarter 2019 CAB. Under "When Covered" section: deleted term "ploidy" and replaced with "DNA index" for clarity. No change to policy intent. Deleted coding table from Billing/Coding section. Deleted CPT codes 86356, 88358, 88361 and added CPT code 88182. Medical Director review 8/2019.
Electrical Bone Growth Stimulation References added. Specialty Matched Consultant Advisory Panel review 7/30/2019. Contradictory statement "Invasive methods of bone growth stimulation may be considered medically necessary when used as an adjunct to surgical treatment of non-union of major long bone fractures" removed from When Covered section of policy.
Erectile Dysfunction AHS - G2132 Reviewed by Avalon 2nd Quarter 2019 CAB. Added "Related Policies" section. Policy Guidelines updated. References updated. Coding table removed from the Billing/Coding section of the policy. Medical Director review 8/2019.
Gene Expression Based Assays for Cancers of Unknown Primary AHS- M2065 Specialty Matched Consultant Advisory Panel 8/21/2019. Reviewed by Avalon 2nd Quarter 2019 CAB. Deleted coding table in Billing/Coding section. Medical Director review 8/2019.
Genetic Testing for Acute Myeloid Leukemia AHS-M2062 Reviewed by Avalon 2nd Quarter 2019 CAB. Deleted coding table from Billing/Coding section. Added statement under Policy Guidelines for clarity "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." Medical Director review 8/2019.
Genetic Testing for Adolescent Idiopathic Scoliosis AHS - M2058 Added code 0004M back to policy. Code was removed erroneously on 8/27/19.
Genetic Testing for Alpha- and Beta- Thalassemia AHS - M2131 Reviewed by Avalon 2nd Quarter 2019 CAB with title change. Added characteristics of beta-thalassemia and Related Policies to the Description section. Indications for beta-thalassemia added to the policy statement along with both the When Covered and When Not Covered sections. Policy guidelines updated. Added the following codes to the Billing/Coding section: S3845, S3846, and removed code table. References updated. Medical Director review 8/2019.
Genetic Testing for Diagnosis of Inherited Peripheral Neuropathies AHS - M2072 Reviewed by Avalon 2nd Quarter 2019 CAB. Related Policies added to Description section. When Covered section revised as follows: Item 1, added "or other inherited peripheral neuropathies"; item 2, added "If results indicate a demyelinating neuropathy, then first test for the most commonly identified CMT subtype, CMT1A (PMP22 duplication.", and removed items a. and b. related to specific values for velocity testing in nerve conduction and specific cascade testing; added item 6 for Genetic testing for Hereditary Motor Neuropathy (HMN) (BSCL2 gene), and added "Note" which refers to policy, General Genetic Testing, Germline Disorders AHS - M2145 for all other uncommon hereditary peripheral neuropathy gene testing. Removed the following statement from the When Not Covered section: "Genetic testing for all other inherited peripheral neuropathies is considered investigational". Code table removed from the Billing/Coding section and reimbursement statement added. Policy guidelines and references updated. Medical Director review.
Genetic Testing for Familial Alzheimer's Disease AHS - M2038 Added codes 81401, 81405, 81406, 81407, 96040, S0265, and S3852 back to policy. Codes were removed erroneously on 8/27/19.
Genetic Testing for Hereditary Hearing Loss AHS - G2148 Reviewed by Avalon 2nd Quarter 2019 CAB with title change. Added Related Policies to the Description section. The following were added to the When Covered section: Item 1, "and is recommended" regarding genetic counseling; item 3, removed reference to Table 1-3 in background section and added "ALL of the following are met": for items a and b; added item 5. Added "If more than once per lifetime" to When Not Covered section. Policy guidelines and references updated. Removed the following codes from the Billing/Coding section: 96040, S0265, along with the code table. Medical Director review 8/2019.
Genetic Testing for Hereditary Pancreatitis AHS - M2079 Reviewed by Avalon 2nd Quarter 2019 CAB. Related Policies added to Description section. Minor revision to When Covered section; removed "Unexplained pancreatitis with" from item 1c. Policy guidelines and references updated. Code table removed from Billing/Coding section. Medical Director review 8/2019.
Genetic Testing for Neurofibromatosis and Related Disorders AHS-M2134 Reviewed by Avalon 2nd Quarter 2019 CAB with title change. Description updated, and Related Policies added to this section. Policy statement updated with the addition of "and related disorders" to coincide with title change. The following revisions were made to the When Covered section: item 1: added "schwannomatosis, Legius Syndrome, and Constitutional Mismatch Repair deficiency (CMMRD)", and added items 7, 8, and 9. Policy guidelines extensively revised. The following codes were added to the Billing/Coding section: 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81479, and the following codes were removed along with the code table: 96040, S0265. References updated. Medical Director review 8/2019.
Genetic Testing for PTEN Hamartoma Tumor Syndrome AHS - M2087 Reviewed by Avalon 2nd Quarter 2019 CAB. Added Related Policies to the Description section. Reference to "Note" added to the When Not Covered section. Policy guidelines and references updated. "Note" "5 or more gene tests being run on the same platform, such as multi-gene panel next generation sequencing, please refer to Laboratory Procedures Reimbursement Policy AHS - R2162" added to the Billing/Coding section and code table removed. Medical Director review 8/2019.
HIV Genotyping and Phenotyping AHS - M2093 Reviewed by Avalon 2nd Quarter 2019 CAB. Added "Related Policies" section. Policy Guidelines updated. References updated. Coding table removed from the Billing/Coding section of the policy. Medical Director review 8/2019.
Hormonal Testing in Males AHS - G2013 Policy coverage criteria updated. Removed once in a lifetime limit from #10 in the when covered section. Added to when covered section #11; stating measurement of serum prolactin, LH, FSH, growth hormone (GH), thyroid stimulating hormone (TSH), and adrenocorticotropic hormone (ACTH) are medically necessary in the diagnosis and management of pituitary adenoma and in the diagnosis of hypopituitarism. Added to #5 of when not covered section, "with ambiguous genitalia, hypospadias, or microphallus." Coding table removed. Codes listed and added 84443, 83003, and 82024.
Intensity Modulated Radiation Therapy (IMRT) of Abdomen and Pelvis Under "When Covered" section: removed "with gross nodal disease" from statement 3 c. Medical Director review 9.2019.
Laser Treatment of Port Wine Stains Specialty Matched Consultant Advisory Panel review 8/20/2019. No change to policy statement.
Multigene Expression Assay for Predicting Colon Cancer Recurrence AHS-M2111 Reviewed by Avalon 2nd Quarter 2019 CAB. Deleted coding table from Billing/Coding section. Deleted CPT code 81504. Medical Director review 8/2019.
Myoelectric Prosthetic Components for the Upper Limb Specialty Matched Consultant Advisory Panel review 7/30/2019.
New-To-Market Specialty Drug PPA Requirements Updated policy to include coverage for new indications for a specialty drug when the indication has been added to existing FDA labelling for a drug that is addressed in a specific medical policy but the new indication is not. Medical Director review 9/2019.
Ocrelizumab (Ocrevus®) Updated "When Covered" section with the following clarification for relapsing forms of multiple sclerosis: "(to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease)." Reference added. Medical Director review 9/2019.
Radiosurgery, Stereotactic Approach Under "When Covered" section, added bullet #5 to section B: Pancreatic adenocarcinoma as definitive treatment for inoperable disease without evidence of distant metastases." Medical Director review 9/2019.
Reconstructive Eyelid Surgery and Brow Lift Specialty Matched Consultant Advisory Panel review 8/20/2019. No change to policy statement.
Surgery for Groin Pain in Athletes Specialty Matched Consultant Advisory Panel review 7/30/2019.
Surgical Treatment of Chest Wall Deformities (Congenital or Acquired) Specialty Matched Consultant Advisory Panel 8/20/2019. No change to policy statement.
Testing for Alpha-1 Antitrypsin Deficiency AHS-M2068 Reviewed by Avalon 2nd Quarter 2019 CAB with title change. Made the following changes to the When Covered section: reordered and separated indications into two subclasses: serum testing and genetic testing; added indication stating when serum testing of antitrypsin levels is medically necessary; separated IEF and genetic testing indications and made a separate indication for genetic testing of high-risk individuals due to first-degree relative positive for AATD for clarity. Policy guidelines revised and updated. Added the following code to the Billing/Coding section: 81479 and removed code table. References updated. Medical Director review 8/2019.
Tumor Tissue Mutation Analysis in Colorectal Cancer AHS - M2026 Specialty Matched Consultant Advisory Panel 8/21/19. Reviewed by Avalon 2nd Quarter 2019 CAB. Title changed from KRAS, NRAS, and BRAF Mutation Analysis in Colorectal Cancer to Tumor Tissue Mutation Analysis in Colorectal Cancer. Under "When Covered" section: added "NOTE: For more than 5 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 policy AHS-2109 Molecular Panel Testing of Cancers to Identify Targeted Therapy" for clarity; and removed "E" from BRAF V600E" as other mutations may exist. Added "Related Policies" section. Coding table removed from Billing/Coding section. Medical Director review 8/2019.
Vertebral Axial Decompression (VAD-X) Reference added. Specialty Matched Consultant Advisory Panel review 7/30/2019.
Whole Genome and Whole Exome Sequencing AHS - M2032 Reviewed by Avalon 2nd Quarter 2019 CAB with title change. Added Related Policies to Description section. The following statement was added to the When Covered section: "and comparator analysis (e.g. parents/siblings) whole exome sequencing"; Minor revision to When Not Covered with replacement of "whole exome sequencing" with "WES". Policy guidelines and references updated. Added the following codes to the Billing/Coding section: 0010U, 0012U, 0013U, 0014U, 0036U, and 0094U, and removed code table. Medical Director reviewed 8/2019.
ZIKA Virus Risk Assessment AHS - G2133 Added codes 86794 and 87662 back to policy. Codes were removed erroneously on 8/27/19.